*Purpose: Discard rates of deceased donor kidney transplants(DDKT)rises as the kidney donor profile index(KDPI)increases,and approaches 60%for KDPI of >85%.Pulsatile machine perfusion(MP)allows use of kidneys with prolonged cold ischemia times(CIT).We present our single center data using high risk kidneys KDPI>85 and prolonged CIT and correlate with clinical outcomes of delayed graft function(DGF)and renal function.

*Methods: We retrospectively analyzed outcomes from 01/2014 and 10/2018 of adult DDKTs.We correlated KDPI, CIT, local vs imported kidneys to DGF rates and renal outcome, serum creatinine(scret) at end of study, 11/2018. All DD kidneys were placed on pulsatile(MP)(Lifeport) with KPS-1 preservation solution, upon arrival to our center.Kidney biopsies were performed and pump pressures were monitored. Kidneys were transplanted if pathology and pump parameters were favorable (mean flow>100ml/min and resistance< 0.4).We excluded multiorgan transplants and if patient died within 30 days post transplant.For recipients who lost their allograft or died with functioning graft,we used the scret prior to the decline of graft function or death.

*Results: A total of 1070 recipients were analyzed.The median time from date of transplant to last follow up was 22.3months(range 1.0 to 58.6).Mean KDPI increased overtime from 49% to 61% as did the %of accepted DDT with KDPI>85.Table1.Mean CIT increased from 26 to 32hrs, due to higher rate of imported kidneys.Overall DGF rates were 18.2%.Lowest DGF rate was for KDPI<85% and CIT<24hrs, 3.6% for local and 0% for imported;highest DGF rates were among imported kidneys with KDPI>85 and CIT>24hrs, at 33%. Logistic regression analysis identified predictors of DGF as CIT>24hrs(p=0.00002) and KDPI>85(p=0.01)whereas for scret at last follow up was KDPI>85, import status and DGF but not CIT.Mean scret range from 1.09 to 1.85mg/dl;mean scret from imported kidneys with KDPI>85 and with DGF was 1.49mg/dl.No cases of primary non function or thrombosis occurred in this cohort.Graft loss was 4.7% and patient death was 4.5%.

*from imported kidneys; **Geometric mean values mg/dl

*Conclusions: In an effort to decrease discard rates,especially with imported kidneys, the use of pulsatile MP increases the chances to transplant kidneys with KDPI>85 and long CIT. Despite higher rates of DGF, the mean scret at last follow up was stable and supports continued acceptance of high risk kidneys in order to decrease discard rates.Cold storage,time on the pump and rejection rates are being analyzed.

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